Landscaping of the Urban Poor - IPE Global Limited · of a large urban poor population or the Base of Pyramid (BOP) population (spending

Landscaping of the Urban PoorBrief Description of the Project and Key Findings from PAHAL Diagnostic Study

The United States Agency for International Development works to end extreme poverty and promote resilient, democratic societies. USAID partners with the Government of India and the private sector to eliminate preventable child and maternal deaths, create an AIDS and tuberculosis (TB) free generation, and achieve universal health coverage. For more information, please visit www.usaid.gov/india

IPE Global Limited (IPE Global) is an international development consultancy group providing expert technical assistance in developing countries. The group partners with multilateral and bilateral agencies, governments, corporates and not-for-profit entities in anchoring devel-opment agenda for equitable development and sustainable growth. For more information, please visit www.ipeglobal.com

PAHAL (Partnership for Affordable Healthcare Access and Longevity), a joint initiative of USAID and IPE Global, aims to provide catalytic support to growth stage scalable social enterprises in developing affordable & quality healthcare solutions for the urban poor.

Published in July 2018Copyright © 2018 IPE Global Limited. All right reserved.

PGIMERShankar Prinja

Atul Sharma

Vineeta Sharma

Saroj Kumar Rana

IPE GLOBAL (PAHAL)LM Singh

Amit Bhanot

Dinesh Agarwal

Ajay K Singh

Kaveri Haldar

Medha Verma

Sabiha Mehboob

Aditi Attrey

Sujata Rao

Contributors

Abbreviations 4

Background 5PAHAL | PAHAL Platform | Strategic Framework

Diagnostic Study 9

Maternal and Child Health (MCH) and Family Planning 11Challenges | Government Priority | PAHAL Survey

Out of Pocket Expenditure on Health and Health Insurance 14Challenges | Government Priority | Opportunity | PAHAL Survey

Health Seeking Behaviour 18Challenges | Government Priority | PAHAL Survey

Water, Sanitation and Hygiene (WASH) 20Challenges | Government Priority | Opportunity | PAHAL Survey

Tuberculosis 22Challenges | Government Priority | Opportunity | PAHAL Survey

PAHAL Interventions 24

Fact Sheet 26PAHAL Diagnostic Study

Contents

Abbreviations

AMRUT Atal Mission for Rejuvenation and Urban Transformation

ANC Ante Natal Care

ASHA Accredited Social Health Activist

BOP Base of Pyramid

CAGR Compounded Annual Growth Rate

CAPI Computer Aided Personal Interview

CHE Catastrophic Health Expenditure

DCA Development Credit Authority

DSF Demand-side Financing

EPMCD Ending Preventable Maternal and Child Deaths among India's Urban Poor

FP Family Planning

FRU First Referral Unit

GDP Gross Domestic Product

IBM Inclusive Business Models

ICDS Integrated Child Development Services

IMR Infant Mortality Rate

IPD In-patient Department

MCH Mother and Child Health

MDR-TB Multi-drug-resistant tuberculosis

MGHN Merrygold Health Network

MMR Maternal Mortality Rate

NCD Non-Communicable Disease

AB-NHPM Ayushman Bharat-National Health Protection Mission

NSSO National Sample Survey Organization

OOPE Out of Pocket Expenses

OPD Out-patient Department

PAHAL Partnerships for Affordable Healthcare Access and Longevity

PNC Post-Natal Care

RMNCH+A Reproductive, Maternal, New-born, Child Health and Adolescent

RSBY Rashtriya Suraksha Bima Yojna

SBM Swachh Bharat Mission

TB Tuberculosis

THE Total Healthcare Expenditure

USAID The United States Agency for International Development

WASH Water, Sanitation and Hygiene

WHO World Health Organisation

Landscaping of the Urban Poor4

Background

India has poor healthcare indicators when benchmarked with WHO set standards and an ever changing demography, lifestyle pattern and disease burden makes it difficult to address the healthcare challenges via the traditional healthcare delivery mechanisms. This compounded

with lower public and overall expenditure on healthcare (at 1.15% and 4.8% of the country’s GDP) creates a worrisome situation for India’s underserved and vulnerable population. Adding to the situation is the low health insurance penetration and high out-of-pocket expenditure which leads to over 39 million people being pushed to poverty every year.

Further, rapid urbanization and unplanned growth of cities in India has led to the creation of a large urban poor population or the Base of Pyramid (BOP) population (spending <$8 a day). They live in squalid conditions and lack access to basic necessities like clean water, education and healthcare. They face a disproportionate burden of ill health and high out of pocket expenditure, creating a severe unmet need for affordable and quality health care.

>71%Households WithoutInsurance

>71%Hospitals and Clinics in Private Sector

63%Out of Pocket Expenditure on Health

100Estimated Urban Poor

Million+583Urban population to grow by 2030

Million

Landscaping of the Urban Poor 5

On the other hand, India’s healthcare sector is growing at a CAGR of 23% and will be a $280 billion industry by 2020. India is witnessing rapid urbanization and rising income levels. By 2030, over 40% Indians will be living in urban areas, accounting for 69% of the GDP, implying higher number of underserved urban poor with a capacity to pay, indicating a huge market opportunity.

The private sector, powered by the growth of social enterprises, provides more than 71% of the healthcare services. It is tapping into this opportunity and has been at the fore front of combining innovation in technology and inclusive business models to create scalable social enterprises making quality healthcare accessible and affordable to the population. However, these social enterprises, at an early stage, face challenges including lack of growth capital, access to newer markets, low cost of products and thin margins, etc. making it difficult for them to scale.

There is an evident need for a larger alignment of private and public players for catalyzing these innovations and developing new business models to address the healthcare challenges, which PAHAL intends to provide.

PAHALPAHAL (Partnerships for Affordable Healthcare Access and Longevity), a joint initiative of United States Agency for International Development (USAID) and IPE Global, aims to provide catalytic support to growth stage scalable social enterprises in developing affordable & quality healthcare solutions for the urban poor. PAHAL is a collaborative platform which seeks to connect, capacitate and catalyze innovative social enterprises focused on improving health outcomes among urban poor communities.

Reach10 Million

Urban Poor in India

Reduce out of pocket expenditure on healthcare

for underserved urban communities by 30%

in coverage areas

Background


PAHAL PLATFORMThe project has collaborated with healthcare provider networks consisting of 700+ hospitals, 1,000+ doctors and over 15,000 community workers and owning an exclusive health care delivery model with the objective of reaching out to 10 million urban poor and reducing out of pocket expenditure by 30%.

STRATEGIC FRAMEWORK

700+Health Facilities

3,000+Doctors

15,000+Health Workers

10MillionUrban Beneficiaries

PAHAL has adopted a holistic ecosystem

approach to strengthen and scale market based healthcare solutions to improve access to quality healthcare for underserved urban communities. The project focus is to identify innovative business models, and then provide them with Technical Assistance, Market Access and Access to Capital.

ACCESS TO CAPITAL• Grants• Debt• Equity

SocialEnterprises

TECHNICAL ASSISTANCE• Strengthening Business Models• Strengthening Outreach• Enabling Technology• Positioning Brand Equity

ACCESS TO MARKET• Demand for Health Services• Affordable Health Insurance• Expanding Last Mile Reach

SOME OF THE STRATEGIC INTERVENTIONS OF THE PROJECT ARE


Background

PAHAL is uniquely positioned with a balanced team of experts from financial advisory, strategic advisory, investment, public health, Monitoring and Evaluation and policy.

STRATEGIC PARTNERSHIPSPAHAL has built strategic partnerships with several social enterprises in healthcare delivery, innovation, medical technology, skill building, financing, insurance to develop solutions for improving access and reducing cost of quality healthcare.


Diagnostic StudyPAHAL is implementing cross cutting Monitoring, Learning and Evaluation activities to assess the attribution/contribution of the strategic interventions, and share scientific evidence based insights and learning for knowledge sharing and advocacy with various stakeholders. PAHAL has a team of MLE experts who contribute towards providing regular scientific data by monitoring project indicators from project partners and focus on aligning the strategic interventions to reach the target goal.

A diagnostic study was conducted to understand key areas of health seeking behaviour, access to affordable healthcare and payment capacities of the community before identifying social enterprises with most innovative solutions to provide affordable healthcare services. The study was conducted in selected districts of four project states. The selection of districts was based on RMNCH+A composite index score.

ObjectiveThe objective of the survey was to provide information on relevant health, mortality and morbidity indicators linked to maternal, neo-natal, child health (MNCH), Family Planning (FP) and TB (including awareness, diagnosis, treatment and referral); knowledge, attitude, practice, access, health services utilization pattern, enrolment in health spending support schemes like insurance and out of pocket expenditure (OOPE) on health.

RAJASTHAN

TELANGANA

ODISHA

WESTBENGAL

Jaipur

Bharatpur

MedchalGanjam

Puri

Nadia


The diagnostic survey focused on key health domains such as:

v Mother and Child Health

v Out of Pocket Expenses on Health Including Insurance Coverage

v Health Seeking Behaviour

v WASH

v Tuberculosis

Target RespondentsTarget respondents for the quantitative data collection were• Women who were pregnant any time during the last one year • Mothers of children aged 0-5 years

MethodologyA structured survey schedule was used to collect information from the selected respondents. CAPI (Computer Aided Personal Interview) technique was used to solicit information from the consenting respondents.

Diagnostic Study

RAJASTHANBharatpur & Jaipur

TELANGANAMedchal

WEST BENGALNadia

ODISHAGanjam & Puri

SAMPLING

50 RESPONDENTS FROM EACH PSU

4 PSUs FROM EACH DISTRICT (n=26)

Only 2 PSUs from WB


Total Sample N=2,438

CHALLENGESMaternal and Child health remains a grave challenge for healthcare systems worldwide, which calls for a global reduction in interdependent Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR). According to NFHS-4 data more than 12 states and 10 out of the 12 states surveyed have not been able to reduce the IMR even by 2% annually1.

GOVERNMENT PRIORITYv Announcement to set up ‘Mahila Shakti Kendra’ at the village level with an allocation of

`500 crore for 14 lakh ICDS Anganwadi Centres.v ̀ 6,000 allocated for each pregnant woman to encourage ownership of a bank account, have

institutional delivery and vaccinate their children2. (Under the Maternity Benefit Scheme). v Action plan to: w Reduce IMR from 39 in 2014 to 28 by 2019 and MMR from 167 in 2011-13 to 100 by 2018-2020.w Increase the number of pregnant women receiving 3 Antenatal Care (ANC) check-ups,

institutional deliveries, the number of First Referral Units (FRUs), number of sick newborns admitted to the Facility Based Newborn care units and ‘Full Immunisation Coverage’.

1 Ganotra K. Union Budget 2017: Declining investment, increasing malnutrition – The story of our country’s children [Internet]. New Delhi: The Financial Express; 2017.

2 Jaitley A. Budget Speech 2017-18 Internet]. Union Budget; 2017.

PAHAL SURVEYThe key mother and child health findings are:

Full ANC Coverage (%)

Odisha Combined

West Bengal Telangana Rajasthan

42.3

12.521.3

23.3

26.5

West Bengal Telangana Rajasthan Odisha Combined

73.6

47.7 53.2

71.762.6

Women Reporting 4 ANC Visits (%)

Only around two-third of women had 4 ANC visits during their pregnancy.

The coverage of full ANC* was only 27%.

* Full ANC Coverage: At least four ANC visits, at least one tetanus toxoid (TT) injection and iron folic acid tablets or syrup for 100 or more days.

50%of under 5 children are anaemic

246per 100,000 live births in EAG statesMMR at

MCH & Family Planning


Unmet Need for Family Planning (%)

West Bengal & Rajasthan Have High Unmet Need


10.215.4

25.6

7.811.7

19.5

4.82.6

7.4

16.5

34.8

51.3

14.3

23.6

9.3

Unmet Need for Spacing Unmet Need for Limiting Total Unmet Need for Family Planning

MCH & Family Planning


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ndia

/Ro

bin

Wya

tt


Women Who Breast fed their Child within One Hour

of Birth (%)


59.4

75.2

43.9

80.2

65.4

Only 65% of women breastfed their child within an hour of birth. Rajasthan (44%). and West Bengal (59%) needs more attention.

Children aged 12-23 Months who Received Complete

Immunization (%)


89.7

66.0

46.8

85.3

74.3

About ¾ of the children aged 12-23 months received full immunization.


44.4

36.2

44.9

62.7

45.2

Exclusive Breastfeeding for atleast 6 Months (%)

Penetration of exclusive breastfeeding was very low (45.2%).

Postnatal care received within 2 days of delivery (%)


80.6

7.4

35.0

71.1

46.6

Post-natal check up coverage (within 2 days of delivery) was low (47%). Telangana and Rajasthan need more focus.

OOPE & Health InsuranceOut of Pocket Expenditure on Health and Health Insurance

CHALLENGESIndia’s out-of-pocket expenditure on health, pegged at ~60% is one of the highest in the world. In 2013-14, the Total Healthcare Expenditure (THE) of India was 4% of the Gross Domestic Product (GDP). Rising prices have left a large number of people unable to access healthcare in India which is aggravated by low insurance coverage. Abysmally low government spending on health, constituting just 1.15% of GDP catering to preventive, promotive and primary care programmes and private healthcare expenditure constituting of 4.25% of GDP catering to curative services along with 30% of Catastrophic Health Expenditure (CHE) – the lowest among the BRICS nations, make the OOPE very high.

60%highest Out of Pocket Expenditure (OOPE) in the world

90%of the population has no health insurance

=10

Over the period the private health care expenditure has grown at the rate of 12.84% per annum and for each one percent increase in per capita income the private health care

expenditure has increased by 1.47%3. Number of private doctors and private clinical facilities are also expanding exponentially.


3 Dr. Saroj Hiremath, “Insurance Sector- Challenges & Opportunities”, Insurance Times, May 2013.

OOPE & Health Insurance

GOVERNMENT PRIORITYThe recent launch of Ayushman Bharat-National Health Protection Mission (AB-NHPM) seeks to provide health insurance to 10 crore poor and vulnerable households under which up to `5 lakh insurance cover will be provided to each family per year in secondary and tertiary care institutions and will benefit 50 crore beneficiaries, making it world’s largest government-funded healthcare programme to provide quality health cover. These initiatives might reduce OOPE on health significantly in future.

OPPORTUNITYThe out-of-pocket expenses leave a big gap between the healthcare financing needs of an individual and what is on offer in current health insurance products, which need to be filled. Given that government has liberalized the insurance industry, health insurance is going to develop rapidly in the future. With the announcement of the Ayushman Bharat Scheme, there is increasing emphasis on finding synergies between the public and private sector and the government is increasingly trying to leverage private sector resources to provide insurance coverage to the underserved.

80%not covered by any insurance, dependent on private sector for treatment

13%12%rural people are covered through government health insurance despite 7 years of centre-run RSBY

Only urban & 86%population and of theurban population were not covered under any scheme of health expenditure support

Around of the rural

82%

As per the recent NSSO data (April 2018):

Indian health financing scenario raises a number of challenges, which are: v Increasing health care costs, v High financial burden on poor, eroding their savings, v Increasing burden of new diseases and health risks and v Neglecting preventive and primary care and public health functions due to underfunding

OOPE & Health Insurance

76.2 81.3

97.294.3 87.2

OOPE among Urban Poor in PAHAL assessment States (%)


Around two third of total OOPE goes towards hospital-isation and medicines and another 12% in Diag-nostic.

Transportation`467

Doctor's Fee`681

Other Expenses`396

Diagnostic Tests`772

Hospitalization`2,150

How do Household Spend on Health-OOPE

33.2

32.1

5.97.0

10.2

11.5

Medicine`2,221

Two third amount goes in to hospi-talization and medicines.

*This is a multiple response data

How do Households Meet the Health Expenditure (%)

86.4

Personal Savings

21.0

Household Income

7.8

Friends/Relatives

4.6

Loans (Banks/Relatives/Friends)

1.6Other

3,075

8,1168,567 8,569

6,689

4.8

9.0

6.35.2

Healthcare Expenditure out of total Household

Expenditure

WestBengal

Telangana Rajasthan Odisha Combined

Hea

lthca

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xpen

ses

as p

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tota

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sum

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(%

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Mea

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alth

care

exp

ense

s in

last

12

mon

ths

(`)

2.6

At 9% the healthcare expenses out of total health expenses was highest in odisha.

Average fam-ily expendi-ture is `6,689 per annum.

PAHAL SURVEYThe survey conducted by PAHAL program suggests that the total OOPE on health in the selected states was 87.2% and this is consitent across all the states. This high OOPE can be attributed to low insurance coverage among the urban poor.


The PAHAL survey suggests that overall, the insurance coverage was only 12.8%, with highest coverage was reported from West Bengal 23.8% followed by Odisha with 18.7%. However, in both the states, they were largerly covered through RSBY. Out of the 12.8% that were insured, only 7% of them received benefits during last one year.

Awareness about Social Security and Insurance Schemes (%)

Aware of any 1 scheme RSBY CGHS

Pradhan Mantri Suraksha Bima Yojna Pradhan Mantri Jivan Jyoti Bima Yojna Atal Pension Yojna


69.0

44.1

44.4

32.0 38

.224

.5

20.2

1.9

0.0 5.

2 10.1

5.4

25.0

4.2 5.

9 9.2 11

.6 13.2

61.3

51.6

0.0

16.2

15.0

24.2

45.4

24.3

23.6

16.4 20

.416

.0

Insurance Coverage (%)

23.8

18.7

2.8

5.7

12.8


The survey conducted by PAHAL also showed that the coverage of insurance was only 10% and in majority of the cases the respondents were not aware about the various health schemes. The survey showed that although the awareness level about any health scheme was high in states like Odisha, and Rajasthan but it was largely contributed by their awareness of RSBY schemes, while both these states were not aware of any other health insurance schemes of the Government of India.

Health Seeking BehaviourCHALLENGESAccording to NSS findings, the last two decades have seen an asymmetric distribution of patients across public and private health facilities. Most households prefer private health facilities owing to dissatisfaction with and inaccessibility to government healthcare systems. This is a major cause of concern for those residing in semi-urban and rural areas, where access to basic primary healthcare services remains dismal.

PAHAL SURVEYAccording to the survey, the overall preference for private healthcare facility was 31%, dominated by Rajasthan (55%) and Telangana (48%).

GOVERNMENT PRIORITYThe Niti Aayog has suggested a model that provides for a greater role for private players in India’s healthcare sector which has reignited the debate on the merits of involving the private sector in medical care.

32% of hospitalization in urban areas are in public facilities 42% of hospitalization in rural areas are

in public facilities

68% of hospitalization in urban areas are in private facilities 58% of hospitalization in rural areas are

in private facilities

Source: 71st National Sample Survey

Choice of Health Facility for Last Hospitalization (%)

Public Private Facility IBM Facility


73.0

39.143.5

77.5

65.9

25.8

47.854.6

21.731.1

1.1 1.9 0.73.0

13.0


Most women across all the states, preferred to approach a public facility for their last delivery. The demand for delivery for private health facility was close to two fifth.

Place of Last Delivery (%)


59.5

4.0

35.639.4 39.8

10.4 10.4

67.3

84.0

1.0 2.3 2.0 2.2 0.0

13.8

5.5 4.2

32.1

58.3

28.4

Public Facilities IBM Facilities Private Facilities At Home


WASH Water, Sanitation and Hygiene

CHALLENGESUrban India is plagued with multiple Water, Sanitation and Hygiene (WASH) challenges which are directly linked to fatal diseases and conditions such as cholera and diarrhoea along with malnutrition, pneumonia, parasites and blinding trachoma. Most of these diseases are caused by the contamination of drinking water, hands, soil and food with human faeces. India tops the global list of countries with the largest urban population without access to sanitation, and an annual urbanization rate of 2.1%4 further compounds this problem. These challenges are exacerbated by the lack of water availability, outdated technology, poor design* and construction quality of toilets and the behavioural issue of improper public toilet usage.

GOVERNMENT PRIORITYGovernment of India’s flagship scheme – the Swachh Bharat Mission (SBM), along with the Atal Mission for Rejuvenation and Urban Transformation (AMRUT) Programme have taken a big step towards making India open defecation free by 2020. SBM has shown considerable progress by constructing individual household toilets, public and community toilets across

rural and urban areas and has also moved a step forward in proper waste collection and management.

OPPORTUNITYDensely populated cities, combined with rapid urbanization and India’s limited urban WASH infrastructure continue to create bottlenecks in the realization of the Indian Government’s efforts with the Swachh Bharat

Mission and AMRUT Programme.

Moreover, India lacks a comprehensive scheme for safe drinking water. All Indian water bodies within and near population centres are now grossly polluted

with organic and hazardous pollutants. The Asian Development Bank has forecast that by 2030, India will have a water deficit of 50%.

Alliances of individuals, government organizations, the non-profit sector, development experts, investors and businesses together using

their diverse perspectives and resources can jointly address these issues, thereby ensuring access to safe drinking water and sanitation for all as

envisaged in the Sustainable Development Goals.

63 MillionIndians without clean drinking water

140,000Children die from diarrheal diseases each year

40%Population practice open defecation

4 GOYAL, N., & Tejas, A. (2018, February 28). A Business Accelerator Puts India’s Urban WASH Challenges Front and Center. Next Million, 1, 10.

PAHAL SURVEYThe diagnostic survey highlighted some key WASH challenges.

Source of Drinking Water (%)

Piped Water Inside the

Home

53.2

Public Tap/Standpipe

Outside Home

10.5

Tube Well or Bore well

16.4

Hand Pump

11.4

Tanker

2.4

Cart with Small Tank

0.1Surface Water

0.5

Bottled Water/Pouch

Water

5.5

Nearly one-third of population uses an unsafe source of drinking water.

Type of Toilet Facility Used (%)

Flush Toilet Inside Home

Toilet Connected with Septic Tank

Pit Latrine Inside Home

Flush Toilet but Outside Home/

Public Flush Toilet

Pit Latrine Outside Home

Use Open Space or Field

22.5

29.2

10.312.9

15.6

9.2

Nearly 28.5% of the population is using latrine outside their house.

9.2% of people defecate in open.

Households Using Non-LPG, Bio/Elecric Means of Cooking Fuel (%)


47.4 47.4

12.6 12.6

28.0

Conventional means of cooking fuel pose a major challenge for Health and Hygiene, particularly in the states of West Bengal and Odisha.


TuberculosisCHALLENGESIndia has highest burden of both TB and MDR TB based on estimates reported in Global TB Report 20165, which is one fourth of the global TB burden.

OPPORTUNITYThe government, in May 2012, made it compulsory for all private health care providers to notify every TB case diagnosed. This was done with the aim of improving the collection of patient care information. Since then, more than 1,13,961 private health establishments are registered under NIKSHAY till December 2016. Among them, 70,146 are private practitioners/clinics, 34,105 are hospitals/clinics/nursing homes and 9,710 are laboratories7. More than half of all the TB patients are catered to by the private sector8.

5 “Global TB Report 2017”, WHO, 20176 ibid

7 https://tbcindia.gov.in/WriteReadData/TB%20India%202017.pdf8 https://www.tbfacts.org/tb-statistics-india/

2.79MillionTB cases reported in India according to WHO

28Lakhnew cases in 2016

1.3Lakhnew cases of MDR-TB

1.1LakhHIV and TB co-infection in 2015-37,000 of them6 died

GOVERNMENT PRIORITYThe Government of India aims to eradicate tuberculosis by 2025 by involving the private sector, NGOs and caregivers to improve early diagnosis, treatment adherence and outcomes for TB patients, and intersectional collaboration between different platforms that promote access to healthcare with regard to tuberculosis.


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Population Diagnosed with TB (%)


0.9

3.52.7

0.5

2.0

Despite having high symptomatic prevalence of TB, the diagnosis of TB remains poor, indicating an unfavourable health seeking behaviour

PAHAL SURVEYAccording to the PAHAL assessment, TB related symptoms were high in the survey sites, despite the awareness about TB being high.

Respondents having Acute TB Symptoms (%)


9.9

20.2

9.5

1.9 0.7 1.0

20.321.8

19.8

0.2 0.7 0.5

7.310.6

6.8

Persistent cough for 2 weeks

Blood during coughing

Persistent cough and Blood during coughing

People in West Bengal and Rajasthan reported highest number of people who had persistent cough for 2 weeks and also reported blood while coughing.

* Dry Cough, Persistent cough for 2 weeks, Cough with phlegm, Cough with blood, Persistent Fever, Sweating, Restlessness, Loss of appetite, Tiredness/Fatigue, Weight loss, Chest Pain

Respondents Having 2 or more TB Symptoms (%)

28.3

5.2

21.0

15.3

34.2

Odisha Combined

West Bengal Telangana Rajasthan

West Bengal and Rajasthan reported highest number of people with 2 or more symptoms of TB*


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STRENGTHENING OUTREACHOutreach is central to the uptake of services for a facility centred health care provider. MerryGold Health Network (MGHN), provides strong community linkages to 700+ urban facilities through its workforce of 15,000 community health workers or Merrytarang Workers. PAHAL works towards supporting MGHN to create an efficient cadre of community health workers that can enable health promotion and disease prevention in communities. The community health workers supports in uptake of primary health care services by triggering behaviour changes by sensitizing the community and creating awareness regarding promotive, preventive and curative healthcare services of MGHN to promote service uptake.

BRAND ENHANCEMENT & MARKETINGPAHAL is working towards brand enhancement of the Merrygold Health Network and provide support for increased awareness and demand-generation through its branding, communication and advocacy team. The aim is to establish MGHN as a network that provides quality healthcare services at affordable prices.

TECHNOLOGY SUPPORTTechnology is an integral part of the expansion strategy and enhances operational effectiveness & customer experience. PAHAL provides technical support to improve data management and reporting, and designing a structured solution which impacts the overall governance of the network.

DEMAND SIDE FINANCING PAHAL focuses on the potential of Demand- side Financing (DSF) schemes with community

participation to reduce out of pocket expenditure. Towards the same a health insurance product has been designed and demonstrated to reduce OOPE

and enhance access to quality health care & improve health seeking behaviour amongst the urban poor.

PAHAL Interventions


STRENGTHENING BUSINESS MODELPAHAL is providing strategic guidance & business advisory in restructuring the MGHN business to create a sustainable and scalable model, which will enable it to attract necessary resources including commercial capital (equity and debt) to fulfil its expansion goals while continuing its existing sources of funding from donors, CSR and government.

ACCESS TO CREDIT At the franchisee level, PAHAL is working towards creating a structured credit product, backed by a loan guarantee- such as the USAID/DCA Loan Guarantee, with a value proposition which is compelling for any bank/NBFC in terms of scale and opportunity to make financial returns. This in turn will improve access to credit for MGHN franchisees and utilization of the DCA guarantee.

CAPITAL ADVISORY & SUPPORT IN FUND MOBILIZATION PAHAL is well networked with social impact investors, private equity funds, financial institutions (banks/NBFCs), corporates and donors. PAHAL is assisting in identification of suitable investors and support in raising capital from investors. PAHAL will undertake an assessment to understand the capital needs, for debt, equity and grant of the social enterprises. PAHAL is also complementing existing CSR fund raise efforts of MGHN.


Indicators West Bengal (%) Telangana (%) Rajasthan (%) Odisha (%) Overall (%)

Socio-Demographic Profile

Average Household size (Mean ± SD) 4.76±1.69 4.10±1.19 5.76 ±2.42 5.16 ±1.80 4.77±1.80

Ethnicity

Scheduled Caste 36.0 36.2 24.5 17.5 31.1

Scheduled Tribes 4.1 14.1 15.6 10.5 10.4

OBC 10.6 24.5 36.9 31.2 23.1

Others 49.3 25.2 23 40.9 35.4

Proportion of Household having Pucca house 42.9 74.3 91.3 69.1 66.0

Proportion of BPL households 43.8 49.2 19.8 64.8 45.1

Health Expenditure and Insurance Coverage

OOPE among urban poor in Pahal Assessment states (%)

76.2 97.2 94.3 81.3 87.2

Proportion of expenses on health in the last 1 month (%)

2.6 6.3 4.8 9.0 5.2

Insurance coverage (%) 23.8 2.8 5.7 18.7 12.8

Community Mobilization

Proportion of Household participating in community related functions, meetings and other events

9.4 9.3 1.2 2.5 6.8

Proportion of women who are member of any Self-Help Group or Youth club or Mahila Mandal

15.0 8.4 0.7 14.5 10.3

Morbidity Pattern

Percentage of people fallen sick in last 15 days

16.9 5.7 21.4 19.2 14.9

Proportion of people who fell sick during last 15 days and did not take any treatment

13.2 19.0 4.6 3.8 9.2

Percentage of People Seeking Treatment (OPD) from:

Public Sector Facilities 45.2 27.4 29.8 45.6 38.7

Private Sector Facilities 38.9 51.0 60.0 47.2 48.8

IBM Health Facility 0.0 21.0 2.2 0.0 2.9

Percentage of People Seeking Treatment (IPD) from:

Public Sector Facilities 73.0 39.1 43.5 77.5 65.9

Private Sector Facilities 25.8 47.8 54.6 21.7 31.1

IBM Health Facility 1.1 13.0 1.9 0.7 3.0

Sources to Meet Healthcare Expenses for Households

Personal income 81.8 84.7 98.3 87.3 86.4

Household income excluding personal income

36.0 20.3 0.5 13.5 21.0

Savings Loans (Banks/Relatives/Friends) 9.9 3.2 0.7 0.7 4.6

Contribution from friends/relatives 6.4 7.6 5.4 13.7 7.8

Selling assets/property 0.5 0.5 0.0 0.5 0.4

Insurance coverage 1.2 0.2 0.5 0.5 0.7

Reimbursement from employer 0.1 0.2 0.0 0.2 0.2

Others 0.2 0.0 1.2 0.2 0.3

Factsheet PAHAL Diagnostic Study


Indicators West Bengal (%) Telangana (%) Rajasthan (%) Odisha (%) Overall (%)

Maternal and Child Health

Proportion of women registered for ANC during last pregnancy

99.7 86.8 92.8 99.2 94.1

Proportion of women registered in their first three months of pregnancy

92.8 57.4 62.9 84.6 74.3

Proportion of women had at least 4 ANC check-ups during last pregnancy

73.6 47.7 53.2 71.7 62.6

Proportion of women who had complete ANC done during last visit

42.3 12.5 21.3 23.3 26.5

Proportion of women had institutional delivery

99.0 89.6 98.0 100.0 95.8

Proportion of women breast feed their child with in an hour of birth

59.4 75.2 43.9 80.2 65.4

Exclusive Breastfeeding for atleast 6 months (%)

44.4 36.2 44.9 62.7 45.2

Proportion of children aged 12-23 months who received complete immunization

89.7 66.0 46.8 85.3 74.3

Childhood Morbidity

Proportion of children who had diarrhea during the last 2 weeks preceding the survey

5.7 0.2 3.7 7.1 3.6

Proportion of Children received ORS Packet Solution for Diarrhea Treatment

61.1 100.0 34.8 68.4 59.0

Proportion of Children who had cough in the last 2 weeks

17.5 1.4 24.2 21.7 13.8

Family Planning Methods

Proportion of Women currently using any FP Methods to avoid pregnancy

37.5 39.1 55.0 51.1 43.2

Unmet need for spacing 10.2 4.8 16.5 7.8 9.3

Unmet need for Limiting 15.4 2.6 34.8 11.7 14.3

Tuberculosis

Proportion of respondents aware of TB as a disease

87.9 16.3 91.1 32.7 54.9

Respondents who reported 2 acute symptoms of TB-Persistent cough for 2 weeks and Blood while coughing

23.3 2.3 30.4 1.0 13.7

Respondents who reported 2 or more symptoms of TB*

28.3 15.3 34.2 5.2 21.0

Respondents who had 2 acute symptoms of TB -Persistent cough for 2 weeks and reported blood while coughing

9.5 1.0 19.8 0.5 6.8

Respondents who reported Persistent cough for 2 weeks

9.9 1.9 20.3 0.2 7.3

Respondents who reported blood during coughing

20.2 0.7 21.8 0.7 10.6

Proportion of population diagnosed with TB 0.9 3.5 2.7 0.5 2.0

Water, Sanitation and Hygiene (WASH)

Open Defecation 2.6 3.0 4.2 40.1 9.2

Piped water inside the home 12.1 84.6 80.4 42.4 53.2

Proportion of household using conventional means of cooking fuel**

47.4 12.6 12.6 47.4 28.0

* TB Symptoms: Dry Cough, Persistent cough for 2 weeks, Cough with phlegm, Cough with blood, Persistent Fever, Sweating, Restlessness, Loss of appetite, Tiredness/ Fatigue, Weight loss, Chest Pain, **Conventional means of cooking fuel includes, Wood, Charcoal, Coal, Kerosene, Straw/shrubs/grass, agricultural crop waste, dung cake


Urban Health (USAID) Project

For more information contact:

L. M. SINGHProject Director, PAHAL and Head-Impact Investment, IPE Global Limited

IPE Global HouseB-84, Defence ColonyNew Delhi-110024, India

Ph: +91 1140755900;Email: [email protected]://www.ipeglobal.com/pahal/

Disclaimer: This publication is made possible by the support of the American People through the United States Agency for International Development (USAID), under the terms of Cooperative Agreement No.AID-386-A-15-00014. The contents of this report are the sole responsibility of IPE Global and do not necessarily reflect the views of USAID or the United States Government.

Des

ign:

Pea

liDez

ine,

peali.duttagupta@

gmail.com

Photo: PCI India/Robin Wyatt

Documents

Landscaping of the Urban Poor - IPE Global Limited · of a large urban poor population or the Base of Pyramid (BOP) population (spending